Know the 2 major arteries (lateral and internal thoracic) and three lymph node groups (axillary, internal thoracic (mammary) and supraclavicular) which supply the breast.
Confusion between lobe, lobule, acini, alveolus, and duct is rampant in clinical medicine, but should never be confusing for you.
A lobule is part of a lobe composed of many acini. Lobules are separated from each other by bands of connective tissue.
Acini are also known as alveoli.
“ Fibrocystic disease” is the waste basket term for benign breast disease characterized by fibrosis, cysts, inflammation, and a host of other benign changes. Certain features such as hyperplasia and papillomatosis, put it in a somewhat higher risk category for future carcinoma.
Breast cyst, filled with fluid, in the pathology lab.
Breast cyst, filled with fluid, in the ultrasound lab.
This image speaks for itself.
Adenosis is defined as an increased number of acini per lobule.
Hence the name, “fibrocystic” disease.
“ Benign” hyperplasia is characterized by, NO necrosis, the presence of MYOEPITHELIAL cells, and NO ATYPIA.
Sclerosing adenosis is often confused with malignancy. Why? Ans: the “sclerosis” can be mistaken for desmoplasia.
VERy very very scary, but 100% benign, lesion.
Note the myoepithelial cell. The presence of myoepithelial cells, means, BENIGN!!!
Our old friend the papillopma, i.e., a fingerlike proliferation of epithelium, growing over a fibrovascular core.
Number 1 commandment in pathology: NEVER diagnosis a malignant papilloma on a frozen section!!!!! NEVER.
The asterisked items, are more suspicious than the non-asterisked items. Intraductal NECROSIS is the most suspicious feature of all.
Note the INTRADUCTAL NECROSIS.
Note the atypia, “swiss cheese” hyperplasia, and early necrosis.
Note the extreme artypia.
Microcalcifications, seen on mammograms, are often the result of necrotic intraductal crud which has calcified.
This type of calcification represents about a 20% chance of malignancy and should be biopsied. This device helps pathologists to sample the areas of greatest concern more heavily.
A whole lobule filled with monotono0us cells of the same type can be called LCIS, or lobular carcinoma in situ.
HER2 is a proto-oncogene located at the long arm of human chromosome 17(17q11.2-q12). Approximately 25-30 percent of breast cancers have an amplification of the HER2/neu gene or overexpression of its protein product. Overexpression of this receptor in breast cancer is associated with increased disease recurrence and worse prognosis. Because of its prognostic role as well as its ability to predict response to trastuzumab , breast tumors are routinely checked for overexpression of HER2/neu. Overexpression also occurs in other cancer such as ovarian cancer and stomach cancer.
90% of infiltrating breast carcinomas are simply called “Infiltrating Ductal Carcinoma” on the pathology report.
The “tubular” pattern is somewhat better in behavior.
The mucinous variant is also somewhat better in behavior.
The medullary variant (i.e., lots of immune calls or lymphocytes) is also somewhat better in behavior.
Note that no matter how big a male’s breasts may get, they should never for m lobules, but just end as blunt ducts.
FEATURES OF “ATYPIA”-LOSS OF STROMA BETWEEN ACINI-“SWISS CHEESE” HYPERPLASIA*-CRIBRIFORMING**-CELLULAR PLEOMORPHISM-CELLULAR HYPERCHROMASIA-INCREASED/ABNORMAL MITOSES*-“ROMAN” BRIDGES***-NECROSIS*** (“COMEDO-carcinoma”)
NORMAL NORMALDUCT ACINUSATYPICAL HYPERPLASIA ATYPICALof DUCT HYPERPLASIA, LOBULE
LCIS-Usually hangs around MANY MANY years before itinfiltrates, in contrast to DCIS-The BEST management may be judicious neglect, i.e.,observation-If it does infiltrate, however, it is at least as bad as DCISinfiltrating, or probably WORSE, showing “indian” files
A whole lobule filled with monotonous cells of the same type can be calledLCIS, or lobular carcinoma in situ.
BREAST CANCERRISK FACTORS-Age-Menarche Age, early menarche is a risk-First Live Birth-First-Degree Relatives with Breast Cancer-Breast Biopsies-Race-Estrogen Exposure-Radiation Exposure-Carcinoma of the Contralateral Breast or Endometrium-Geographic Influence-Diet-Obesity-Exercise-Breast-Feeding, less breast feeding is a risk-Environmental Toxins-Tobacco-ABORTIONS?
BREAST CANCERPROGNOSTIC FACTORS-AGE-GENERAL HEALTH and IMMUNITY-Histologic degree of differentiation, i.e., GRADING-ER/(PR) -Her2-Neu-STAGING, especially POS or NEG lymph nodes,TNM, etc.
HISTOLOGIC CLASSIFICATION-INFILTRATING DUCTAL-INFILTRATING LOBULAR (INDIAN FILE)-TUBULAR (LOOKS LIKE SCLEROSIS, BUT NOBASEMENT MEMBRANE)-MUCINOUS (COLLOID)-MEDULLARY (LOTS of LYMPHOCYTES)
INFILTRATING DUCTAL CA., “TUBULAR” PATTERN or TYPE
INFILTRATING DUCTAL CA., MUCINOUS (COLLOID) PATTERN or TYPE
INFILTRATING DUCTAL CA., MEDULLARY PATTERN or TYPE
PAGET DISEASE OF NIPPLEPaget disease of the breast (also known asPaget disease of the nipple and mammaryPaget disease) is a rare type of cancerinvolving the skin of the nipple. Most people with Paget disease of thebreast also have tumors inside the samebreast.These breast tumors are either ductalcarcinoma in situ or invasive breast cancer
STAGING, TNM,based on biologic behavior-IN-SITU-EARLY disruption of the basal lamina, i.e., basementmembrane-STROMAL infiltration-LYMPHATIC vessels-SENTINAL lymph node metastasis-MORE lymph node metastases-Adjacent structures, skin, ie, “inflammatory”-DISTANT, METASTASES, LIVER, BONE, LUNGS, BRAIN,EVERYWHERE
Which one of the following lesions usuallypresents as a discrete, freely movablenodule in the breast ?A. sclerosing adenosisB. cystic diseaseC. ductal carcinomaD. fibroadenomaE. plasma cell mastitis
A 35-year-old woman noted a lump in thebreast which seemed to be enlarging. Thebreast was biopsied primarily to exclude :A. mastitisB. carcinoma of the breastD. fibrocystic disease of breastE. metastatic carcinoma
Microscopically, a breast lesion iscomposed of dense collagenous stromacontaining small nests and rows of cells thatform rudimentary acinar structures. The cellsare round or polygonal and containhyperchromatic nuclei. Occasional mitosesare present. At the margins of the lesionnests of cells infiltrate fibroadipose tissue.The description applies to :A. fibroadenomaB. fibrocystic diseaseC. infiltrating ductal carcinomaD. medullary carcinoma
A lesion from the breast of a 60-year-oldwoman contains a firm area 3 cm indiameter with irregular, ill-defined margins.The lesion is densely fibrous and gritty. Thesectioned surface is gray, slightly depressedand opaque. Cords of fibrotic tissue extendirregularly into surrounding adipose tissue. Themost likely diagnosis is :A. fat necrosisB. fibrocystic diseaseC. Infiltrating ductal carcinomaD. medullary carcinomaE. colloid carcinoma
Bleeding from the nipple in a 45-year-oldwoman, without a palpable breast massshould suggest :A. fibroadenomaB. sclerosing adenosisC. fat necrosisD. intraductal papillomaE. chronic cystic mastitis
Paget’s disease of the nipple presupposesthe existence of :A. ductal carcinomaB. simple eczemaC. lobular carcinomaD. abnormal estrogen stimulationE. sclerosing adenosis
The most common breast neoplasm (benignor malignant) found in young females (age20—35) is :A. duct papillomaB. adenocarcinomaC. fibroadenomaD. sarcoma
Paget’s disease of the nipple has all of thefollowing characteristics exceptA. is a neoplastic breast disease involvingthe epidermisB. histologically shows characteristic largeclear cellsC. is part of the picture of long standingfibrocystic diseaseD. is associated with intraductal carcinoma
All of the following are associated with anincreased risk of breast cancer except :A. a previous mastectomy for cancerB. a maternal history of breast cancerC. breast feedingD. increasing age beyond 50 years
Of the following breast lesions, which is mostcharacteristically bilateral :A. fat necrosisB. fibroadenomaC. intraductal papilloma of nipple ductsD. lobular carcinoma-in-situE. Paget’s disease
A 60-year-old woman comes to your office forevaluation of a breast “lump.” About 4 months ago shenoticed a “hard” but painless area along the lateralaspect of her left breast. She has previously had minorchest trauma and thought the lump was a scar. Shestates that this hard area is now larger than when shefirst noticed it. There is a 5 cm firm area in the upperouter quadrant which seems firmly attached to thechest wall. The overlying skin is dimpled but the mass ispainless. There is a firm 2 cm nodule in the left axilla andher left arm is swollen. The most likely diagnosis is :A. traumatic fat necrosisB. plasma cell mastitisC. Paget’s disease of breastD. inoperable breast cancer
A 24-year-old woman developed a breastlump which had been first noted four monthsbefore she sought a medical opinion. Thetumor was well defined and seemed discrete.What is the most likely diagnosis ?A. fibrocystic diseaseB. fibroadenomaC. sclerosing adenosisD. ductal carcinomaE. medullary carcinoma
In patients with breast cancer, poorprognostic signs include all the followingexcept :A. edema of breast skinB. fixation of tumor to chest wallC. metastases to >3 axillary lymph nodesD. presence of estrogen receptors in tumor